What is the recommended rehabilitation protocol for a patient with a spinal cord injury?

Rehabilitation Protocol for Spinal Cord Injury

Begin rehabilitation as soon as the patient is medically stable in the ICU, focusing on early mobilization once the spine is stabilized, with stretching exercises for at least 20 minutes per zone, pressure ulcer prevention measures, and intermittent urinary catheterization as the primary bladder management strategy. 1

Timing of Rehabilitation Initiation

• Start rehabilitation immediately upon medical stability in the ICU, even before transfer to a dedicated rehabilitation unit 1, 2
• Avoid high-intensity activities (treadmill training, intensive cycling) during the first 3 days post-injury, as these worsen autonomic function, inflammation, and locomotor outcomes 3
• Lower-intensity or voluntary activities (reach training, ladder training, voluntary wheel training) can be safely initiated within the first 3 days 3
• Higher-intensity rehabilitation becomes safer and more beneficial starting at 4 days post-injury 3
• Early activity-based therapy (passive in-bed leg cycling) can be safely initiated within 48-72 hours after surgery with excellent completion rates and no major adverse events 4

Acute Phase Rehabilitation Components (ICU Setting)

Musculoskeletal Management

• Perform stretching exercises for at least 20 minutes per anatomical zone to maintain joint amplitudes and prevent contractures 1
• Apply simple posture orthoses including elbow extension, flexion-torsion of metacarpophalangeal joints, and opening of thumb-index commissure 1
• Position patient correctly in bed and chair to prevent predictable deformities 1
• Focus on strengthening existing musculature from the earliest phase 1

Pressure Ulcer Prevention

Implement the following measures immediately once spine is stabilized: 1

• Early mobilization as soon as spine is stabilized 1
• Visual and tactile checks of all at-risk areas at least once daily 1
• Repositioning every 2-4 hours with pressure zone checks 1
• Use discharge tools (cushions, foam, pillows) to avoid interosseous contact, particularly at knees 1
• Utilize high-level prevention supports (air-loss mattress, dynamic mattress) 1

Bladder Management

• Remove indwelling catheter as soon as patient is medically stable to minimize urological risks 1, 5
• Initiate intermittent urinary catheterization once daily diuresis volume is adequate, as this is the reference method that reduces urinary tract infections, urolithiasis, and increases continence probability 1, 5
• Use a micturition calendar to adapt frequency and schedule of catheterization 1, 5
• Do not treat asymptomatic bacteriuria with antibiotics, as this creates antimicrobial resistance 5

Respiratory Management

• Position patient in semi-recumbent or recumbent position rather than sitting when possible, as this is better tolerated due to gravity effects on abdominal contents and inspiratory capacity 1
• Consider abdominal contention belt to increase tolerance of spontaneous ventilation, particularly in sitting position 1
• For upper cervical injuries (above C5) or complete injuries (ASIA A), anticipate potential need for tracheostomy if vital capacity is reduced by >50% 1
• Perform tracheostomy after 7 days if anterior cervical surgical approach was used; earlier timing possible with posterior approach 1

Pain Management

• Introduce multimodal analgesia during surgical management, combining non-opioid analgesics, antihyperalgesic drugs (ketamine), and opioids to prevent prolonged pain 1
• For neuropathic pain, initiate oral gabapentinoid treatment for more than 6 months 1
• Add tricyclic antidepressants or serotonin reuptake inhibitors when gabapentinoid monotherapy is insufficient 1

Subacute and Ongoing Rehabilitation

Ambulation Training

• Offer body weight-supported treadmill training as an option for ambulation training in addition to conventional overground walking, dependent on resource availability and local expertise 6
• This should only be initiated after the hyperacute phase (>4 days post-injury) to avoid worsening outcomes 3

Upper Extremity Function (Cervical SCI)

• Offer functional electrical stimulation to individuals with acute and subacute cervical SCI to improve hand and upper extremity function 6
• Note that electrical stimulation orthoses have not shown efficacy for recovery of grip capacity 1

Sitting Balance Training

• Do not offer additional unsupported sitting training beyond what is incorporated in standard rehabilitation, as there is no clear benefit 6

Staffing Requirements

• Ensure rehabilitation centers have the equivalent of 2.5 full-time physiotherapists per 15 patients 1

Critical Pitfalls to Avoid

• Do not initiate high-intensity treadmill or intensive cycle training within the first 3 days post-injury, as this worsens inflammation, autonomic dysfunction, and locomotor outcomes 3
• Do not delay removal of indwelling catheters, as prolonged use increases urological complications 1, 5
• Do not treat asymptomatic bacteriuria or rely on pyuria, urine odor, or cloudiness alone to diagnose UTI in catheterized patients 5
• Do not delay rehabilitation until transfer to a dedicated rehabilitation unit; begin in the ICU as soon as medically stable 1, 2
• Do not neglect pressure ulcer prevention measures, as prevalence can reach 26% with sacrum (39%), heels (13%), and ischium (8%) being most affected 1

Interdisciplinary Team Approach

The rehabilitation team must include: 7

• Physiatrist (team leader) 7
• Physiotherapist 7
• Occupational therapist 7
• Respiratory therapist 2
• Dietician 2, 7
• Psychologist 2, 7
• Speech pathologist 2
• Social worker 7
• Nursing staff 2
• Consultant specialists as needed 7